Connect-Home Clinical Trial

Inclusion Criteria for patients: * English-speaking * Have a Minimum Data Set 3.0 Section GG Mobility Assessment Score of 3 or less, indicating the patient requires at least 25-50% assistance for functional mobility * Be diagnosed with at least 1 serious medical illness (neurodegenerative dementia, cancer, chronic kidney disease, cirrhosis, congestive heart failure, chronic obstructive or interstitial lung disease, acute infection with sepsis, acute major motor stroke, acute coronary syndrome, acute hip fracture, diabetes with end organ complications, or intensive care for \>3 days while hospitalized) * Having a caregiver who can be enrolled in the study * For patients with cognitive impairment additional criteria include documentation in the medical record of a caregiver who is the patient's legally authorized representative; and consent of the caregiver to participate in the study as the patient's representative. Inclusion Criteria for Caregivers: * English-speaking * Self-reports assisting the patient at home. Exclusion Criteria for Patients: * Planned hospital readmission for procedures/treatments in next 90 days. There are no exclusion criteria for Caregivers.